Journal of Autism and Developmental Disorders

https://doi.org/10.1007/s10803-018-3558-1

BRIEF REPORT

Brief Report: Postural Balance and Daily Living Skills in Children

and Adolescents with Autism
Aubrey Fisher1,2,3 · Courtney Engel1,2,3 · Robyn Geist1,2,3 · Kristin Lillie1,2,3 · Sagui Lutman1,2,3 ·
Brittany G. Travers1,2,3 

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
The current study investigated the relation between postural balance and performance of daily living skills (DLS) in youth
with autism spectrum disorder (ASD). Fifty-two youth with ASD (6–17 years; IQ ≥ 67) completed standardized balance
testing and parent-reported DLS measures. Results showed a positive association between balance and DLS that was specific
to youth with below-average IQ. While balance challenges were evident across the IQ spectrum, youth with above-average
IQ did not exhibit an association between balance and DLS, perhaps suggestive of compensatory strategies implemented to
offset balance challenges during daily-living tasks. These results underscore the need to better understand the contributions
of motor challenges to DLS in youth with ASD within the context of broader cognitive and environmental factors.

Keywords  Autism spectrum disorder · Daily living skills · Balance · Motor

Introduction may affect the performance of DLS tasks such as grooming,

Daily living skills (DLS) are a major challenge for indi-
viduals with autism spectrum disorder (ASD) (Liss et al.
2001; Perry et  al. 2009). The ability to complete basic
DLS allows individuals to participate independently in the
home and community, making it is essential to understand
the factors that contribute to DLS challenges in ASD. Cur-
rent evidence suggests that age, executive function, symp-
tom severity, and IQ are associated with DLS challenges
(Bal et al. 2015; Duncan and Bishop 2015; Pugliese et al.
2016; Smith et al. 2012), but factors such as atypical motor
skills may additionally contribute to poorer DLS perfor-
mance. Many individuals with ASD exhibit motor impair-
ments (Fournier et al. 2010), and these motor challenges
* Brittany G. Travers
btravers@wisc.edu
1
Occupational Therapy Program, University of Wisconsin-
Madison, 2185 Medical Sciences Center, 1300 University
Avenue, Madison, WI 53706, USA
2
Department of Kinesiology, University
of Wisconsin-Madison, 2185 Medical Sciences Center, 1300
University Avenue, Madison, WI 53706, USA
3
Waisman Center, University of Wisconsin-Madison, 1500
Highland Avenue, Madison, WI 53705, USA
dressing, and household chores. Of these motor challenges,
postural balance may be particularly difficult for individuals
with ASD (Ament et al. 2015), and it is often assumed that
balance challenges impact DLS in this population. Indeed,
everyday tasks such as stepping out of the shower, cooking
at the stove, or dressing become substantially more complex
if one cannot consistently rely on steadiness during standing.
However, no study has directly examined the link between
postural balance and DLS in youth with ASD. The present
study addressed this gap by examining the relation between
standardized measures of balance and DLS in children and
adolescents with ASD, while accounting for factors such as
age and IQ.
Only a handful of studies have examined motor contribu-
tions to DLS in ASD, but the findings suggest that a number
of motor features may be associated with DLS performance
in this population. Sensory features, fine motor, and gross
motor performance were associated with DLS in preschool-
ers with ASD, with the strongest relation existing between
fine motor skills and DLS (Jasmin et al. 2009). Similarly,
motor coordination problems were associated with poorer
DLS in school-aged females with ASD and school-aged
females with attention deficit/hyperactivity disorder, even
when accounting for performance IQ (Kopp et al. 2010).
Longitudinal research by Travers et al. (2017) found that

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manual motor skills (i.e., grip strength and finger-tapping
speed) significantly correlated with current and future DLS
in individuals with ASD from childhood to mid-adulthood,
even after accounting for age and IQ. Taken together, it
appears that fine motor and motor coordination challenges
relate to DLS in ASD, but there is little evidence regarding
the role of balance. Given that many DLS tasks inherently
involve standing and weight-shifting, it is important to deter-
mine if balance impairments are affecting DLS performance
in this population. Understanding this relation could aid in
the development of appropriate motor interventions for chil-
dren and adolescents with ASD in order to promote greater
independence in the home and community. Therefore, the
aim of the present study was to examine the association
between postural balance and DLS performance in children
and adolescents with ASD. Based on the theoretical con-
tributions of balance to DLS as well as evidence that other
motor domains relate to DLS in ASD, we hypothesized that
participants with poorer balance would have poorer perfor-
mance in DLS, above and beyond the effects of age and IQ.
Methods
Design
To examine the relationship between balance and DLS
in children with ASD, a standardized measure of balance
and a standardized measure of DLS were combined across
three concurrent studies within our lab (i.e., two studies that
examined a biofeedback-based balance training and one neu-
roimaging study that examined brain-motor relations). These
measures were collected as part of the intake for all three
studies. All measures, regardless of study, were administered
and scored by the same research team and were adminis-
tered prior to any balance training. The current analyses
were consistent with the aims of all three studies, as the
overarching goal was to better understand motor skills in
youth with ASD.
Participants
All three studies were approved by the University of Wis-
consin-Madison’s Institutional Review Board. All parents
provided written informed consent, and all children provided
informed assent. Fifty-two children and adolescents with
ASD (6–17 years old; 90.4% male) completed the meas-
ures. To be included in these analyses, all participants were
required to have a previous diagnosis of ASD that was sup-
ported by meeting criteria for ASD on Modules 3 or 4 of the
Autism Diagnostic Observation Scale-2nd edition (ADOS-
2) (Lord et  al. 2012). Individuals were excluded from
the study if they had a previous diagnosis of intellectual
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Journal of Autism and Developmental Disorders
disability, a known medical cause of ASD (i.e., fragile-X),
hypoxia–ischemia, seizure disorder, or other neurological
disorders. The sample was representative of the racial com-
position of the USA, per the 2011–2015 estimates of the
U.S. Census Bureau (http://facti​finde​r.censu​s.gov): 65.4%
White, Non-Hispanic; 11.5% Black/African American; 7.7%
Asian; 7.7% White, Hispanic, and 7.7% more than one race.
See Table 1 for additional demographic information.
Measures and Materials
Bruininks–Oseretsky Test of Motor Proficiency—2nd
Edition (BOT‑2) (Bruininks and Bruininks 2005)
The BOT-2 short form and balance subscale were used to
assess overall motor percentiles and balance. The BOT-2
is a standardized assessment of motor abilities that meas-
ures manual coordination, body coordination and balance,
strength and agility, and fine motor skills. The balance sub-
scale uses two-footed and one-footed postures under various
conditions (eyes open, eyes closed, and balance beam) to
evaluate static and dynamic motor skills essential for main-
taining posture while standing and walking. Balance scores
range from 0 to 37, with higher scores indicating better bal-
ance. The BOT-2 is normed for ages 4–21 years and has
demonstrated strong test–retest reliability, strong internal
reliability, and high interrater reliability. Within our lab, all
BOT-2 assessments were live coded by two separate raters,
who used videos of administration and consensus coding to
reconcile any discrepancies.
Vineland Adaptive Behavior Scale, Second Edition (VABS‑II)
(Sparrow et al. 2005)
The VABS-II was administered as a parent/caregiver
report, and the Daily Living Scale was used to assess
age-normed DLS. The Daily Living Scale specifically
Table 1  Demographic characteristics of the sample
N = 52 participants with
ASD (90% male)
Mean (SD) Range
Age (years) 12.60 (3.34) 6.41–17.85
Full scale IQ 103.25 (14.29) 67–135
VABS-II daily living skills standard 90.40 (15.98) 66–117
score
BOT-2 balance score (0–37 range) 27.50 (5.88) 9–37
BOT-2 percentile 14.04 (13.01) 1st–62nd
ASD autism spectrum disorder, BOT-2 Bruininks-Oseretsky Test of
motor proficiency, 2nd edition, VABS-II vineland adaptive behavior
scales, 2nd edition
Journal of Autism and Developmental Disorders

measures age-normed performance of daily living tasks Results

such as household chores, dressing, and grooming. DLS
standard scores were used, with higher scores indicating
stronger DLS. The VABS-II has shown strong internal
consistency and test–retest reliability.
Wechsler Abbreviated Scale of Intelligence‑2nd Edition
(WASI‑II) (Wechsler and Hsiao‑pin 2011)
The WASI-II is an abbreviated measure of intelligence
for ages 6–90 years with strong reliability and validity.
The WASI-II includes four subtests (block design, vocabu-
lary, matrix reasoning, and similarities) to assess verbal
comprehension, perceptual reasoning, and general intel-
lectual ability (full scale IQ). Full scale IQ also has been
shown to be reliably assessed with the two-subtest version
of the WASI-II (block design and vocabulary), although
verbal comprehension and perceptual reasoning cannot be
assessed with two subtests. In the present sample, 75%
(39) of participants received the four-subtest version of
the WASI-II (used by two of the three studies). The other
25% of participants received the two-subtest version (used
by one of the three studies).
Procedures
The intake session was similar across all three studies.
Specifically, after informed consent and assent forms were
signed, the participant completed the ADOS-2, WASI-II,
and BOT-2. While the participant completed these assess-
ments, parents completed the VABS-II.
Data Analysis
The overall multiple regression predicting DLS as a func-
tion of balance, IQ, and age was significant, F(5,46) = 6.77,
p < .001, R2 =. 424 (95% confidence interval: .248–.599),
adjusted R2 = .361. The unstandardized beta coefficients,
their 95% confidence intervals, standard errors, and t-tests
are shown in Table 2. Contrary to our predictions, there
was not a conditional (“main”) effect for balance. How-
ever, we found a significant interaction between balance
and IQ and a main effect for age and a­ ge2. The main effects
for age and ­age2 suggest that DLS standard scores showed
a slight decrease (with an inverted U-shape) as a function
of age within this ASD group. The interaction between
balance and IQ is shown in Fig.  1. While the interac-
tion between balance and IQ in the regression model was
between two continuous variables, Fig. 1 simplifies this
interaction by showing the relation between balance and
DLS scores in those with above-median IQ and those with
below-median IQ (median = 104).
From Fig. 1, we see that there was a positive relation
between balance and DLS performance in individuals with
below-median IQ but not in those with above-median IQ.
Follow-up partial correlational analyses (controlling for
age) confirmed that those with below-median IQ (< = 104)
demonstrated a significant, medium-to-large, positive rela-
tion between balance and DLS, r = + .44, p = .02, whereas
those with higher IQ (> 104) did not exhibit a relation
between balance and DLS, r = − .09, p = .68. To examine
if balance scores differed between the below-median-IQ
group and the above-median-IQ group, we performed an
independent-samples t-test. Similar balance scores were
observed in both the below-median-IQ group (M = 26.59,
SD = 6.25) and the above-median-IQ group (M = 28.48,
SD = 5.42), t(50) = 1.16, p = .25, Cohen’s d = 0.323.

Data analysis was completed using R version 3.2.2 (R Core

Team 2015). To examine DLS as a function of balance, we
fit a standard multiple regression model. Because IQ and
age are known to affect DLS (Liss et al. 2001; Smith et al.
2012), age, a quadratic term for age (­ age2), IQ, and their Table 2  Summary of unstandardized beta coefficients from multiple
interactions were included alongside balance as poten- regression analysis examining predictors of daily living skills (DLS)
tial variables in the regression model. The leaps package standard scores (n = 52)
(Lumley 2017) was used in an exhaustive search to find b 95% CI SE t value p value
which subset of these variables accounted for the most
Intercept 96.88 91.06, 102.71 2.89 33.48 < .001
variance, using adjusted R2 to account for the number of
Balance 0.44 − 0.21, 1.08 0.32 1.36 .18
predictor variables in each model. This procedure led to
IQ 0.22 − 0.05, 0.49 0.12 1.64 .11
the final model: DLS standard scores ~ intercept + balance
Age − 1.98 − 3.09, − 0.88 0.55 − 3.62 < .001
scores + IQ + age + age2 + balance*IQ. To reduce the like-
Age2 − 0.57 − 0.98, − 0.15 0.20 − 2.76 .008
lihood of multicollinearity, all independent variables were
Balance X IQ − 0.04 − 0.08, − 0.00007 0.02 − 2.02 .04
mean-centered. All regression assumptions for the final
model were examined and met. Significant effects are bolded

13

Fig. 1  Daily living skills (DLS) standard scores as a function of
balance and full scale IQ. Balance was found to significantly inter-
act with IQ to predict DLS, suggesting that balance and DLS were
related only in those with lower IQ scores. To illustrate the nature of
this interaction, we performed a median split for IQ (median = 104)
Discussion
The present study is the first, to our knowledge, to investigate
the relation between postural balance and DLS performance
in youth with ASD. Our results suggest that poorer balance
was associated with poorer DLS performance (above-and-
beyond the effects of age) but only in individuals who had
below-average IQ (IQs of 67–104). In those with above-
average IQ (IQs of 105–135), there was no relation between
balance and DLS performance. These results extend upon
previous motor research to suggest that in addition to manual
motor skills (Travers et al. 2017), sensorimotor features (Jas-
min et al. 2009), and motor coordination (Kopp et al. 2010),
balance challenges may contribute to difficulties with DLS
in individuals with ASD. However, in contrast to previous
research, the relation between balance and DLS was spe-
cific to those who scored lower on the IQ assessment, even
though no participant in this study had a diagnosis of co-
occurring intellectual disability. It is unclear whether other
motor skills, such as fine motor skills, also interact with IQ
to predict DLS. However, this is a key avenue for future
research, as the present results suggest that cognition may be
an important factor to consider when examining the impact
of motor skills on DLS, even in youth with ASD without
co-occurring intellectual disability.
Notably, the results suggest that those with lower IQ
scores had similar balance challenges to those with higher
13
Journal of Autism and Developmental Disorders
and plotted the relation between balance and DLS in those with
higher and lower IQs. However, we also used color to demonstrate
individual differences in IQ, as IQ was used as a continuous variable
in all of the analyses. The points on the scatterplot are adjusted for
the main effect of age, as age was a significant predictor in the model
IQ scores, even though the relation between balance and
DLS was observed only in the youth with lower IQ scores.
One possible explanation for this pattern of results is that
individuals with higher IQ may have developed strategies or
routines to compensate for balance challenges during DLS
(i.e. sitting down while dressing, using structural supports to
lean on while completing daily tasks, etc.). In other words,
children and adolescents with ASD with higher IQ may be
finding ways around relying on balance during daily tasks.
While our current measure of DLS did not provide informa-
tion on compensatory strategies, past research has found that
youth with developmental coordination disorder (Missiuna
et al. 2008) and cerebral palsy (Klotz et al. 2013) use cogni-
tive and behavioral strategies to manage motor challenges
during DLS. However, future research is needed to directly
test this possibility in ASD either by inquiring about poten-
tial strategies used during DLS performance or by observing
DLS performance in naturalistic environments.
These results have important implications for interven-
tions that target DLS performance in youth with ASD. The
present results suggest that based on cognitive and motor
profiles, different DLS interventions may be warranted for
different individuals. Therefore, assessing both motor and
cognitive skills prior to any DLS intervention may inform
the best course of action for teaching DLS to an individual
with ASD. Specifically, for youth who are found to have
both balance challenges and lower IQ scores, it is possible
Journal of Autism and Developmental Disorders
that targeting the balance challenges through balance prac-
tice, physical therapy, or occupational therapy, may have
cascading benefits on DLS. Moreover, balance training in
conjunction with teaching and rehearsing DLS may lead to
the greatest gains in DLS in this group. In contrast, youth
with ASD who have higher IQ scores may be strategically
compensating for balance challenges in DLS. Therefore,
we likely need to develop and implement different inter-
vention strategies, as balance interventions are unlikely
to improve DLS performance in individuals who already
have methods for accommodating their balance deficits.
For this group with higher IQ scores, teaching further
behavioral strategies to manage balance challenges may
be a more efficacious approach to improving DLS perfor-
mance than trying to enhance balance itself.
A limitation of the present study is that the parent-
report DLS measure assessed performance across a num-
ber of daily tasks rather than assessing tasks that might
specifically require balance. This may have led to an
underestimation of the role of balance in daily living tasks.
Future research that links balance challenges to specific
daily living tasks will be critical to inform intervention.
Therefore, there is a need to develop and utilize func-
tional assessment tools that measure motor skills during
daily tasks such as upper and lower extremity dressing or
bringing a utensil to the mouth for feeding. An assess-
ment that measures balance and other motor skills during
a functional task would provide the specificity needed to
understand the underlying causes of the observed deficits
in both balance and DLS in ASD. Further, a functional
assessment may be able to exhibit if and how individuals
are compensating for balance challenges during functional
tasks, which our current measure of DLS was unable to do.
The use of more comprehensive, functional assessments
could assist in tailoring specific motor-based interventions
for this population.
In all, while postural balance is often assumed to impact
DLS performance in youth with ASD, the present results
suggest that balance challenges relate to DLS performance
only in youth with ASD who have below-average IQ scores.
This finding suggests a potential interaction between cog-
nition and motor skills that should be accounted for when
trying to understand the underlying causes of poorer DLS
performance in ASD. These findings raise the question of
how motor challenges in ASD combine with other factors
known to be associated with DLS, such as executive function
and symptom severity. Further, these results from individu-
als without a history of co-occurring intellectual disability
raise the question of how balance skills relate to DLS perfor-
mance in individuals with ASD and co-occurring intellectual
disability. Most daily living tasks require some type of motor
involvement. Thus, understanding the contributions of motor
skills in combination with other cognitive and environmental
factors will enhance the design and efficacy of interventions
that target DLS challenges in youth with ASD.
Acknowledgments  This work was supported by the Brain and Behav-
ior Research Foundation’s NARSAD Young Investigator Award [to
BGT], the Hartwell Foundation’s Individual Biomedical Award [to
BGT], and the Eunice Kennedy Shriver National Institute of Child
Health and Human Development [P30 HD003352 and U54 HD090256
to the Waisman Center]. The content is solely the responsibility of
the authors and does not necessarily represent the official views of
the National Institute of Child Health & Development or the National
Institutes of Health. We thank Sarah Brill, Sarah Crook, Olga Dadalko,
Ashley Dinges, Dana Dobbe, Nikki Erickson, Isabelle Gallagher,
Andres Gomez, Larissa Hacker, Lauren Hoover, Sarah Jacquot, Brooke
Koehn, Jenna Lent, Nicole Marczak, Rachel Matz, Kristine McLaugh-
lin, Claire Melin, Molly Pearcy, Carli Peters, Kirstin Peters, Katie Phil-
lips, Jenna Radke, Kailey Sabel, Rachel Samz, Sean Sekelsky, Michele
Severson, Olivia Surgent, Elise Suttner, Josh Tarnoff, Desiree Taylor,
Jake Tenaglia, David Turner, Amin Tmimi, Caitie Van Sloun, Matthew
Walczak, Shannon Wittel, and Oskar Zarzycki for their contributions
to this project. We sincerely thank all the families who participated in
this study.
Author Contributions  All authors participated in the conception,
design, coordination, analysis, and interpretation of the data. All
authors assisted in drafting the manuscript. BGT oversaw all aspects
of the study and finalized data analysis, interpretation, and the drafting
of the manuscript. All authors read and approved the final manuscript.
Compliance with Ethical Standards 
Conflict of interest  All the authors declares that they have no conflict
of interest.
Ethical Approval  This project was approved the University of Wis-
consin-Madison Education and Social/Behavioral Science Institutional
Review Board (protocol #2014-1248) and Health Sciences Institutional
Review Board (protocols #2014-1499 and #2016-0441).
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